Provider Demographics
NPI:1811098817
Name:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA
Entity type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:KUYKENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:706-542-8638
Mailing Address - Street 1:55 CARLTON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30602-1503
Mailing Address - Country:US
Mailing Address - Phone:706-542-8638
Mailing Address - Fax:706-583-0217
Practice Address - Street 1:55 CARLTON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-1503
Practice Address - Country:US
Practice Address - Phone:706-542-8638
Practice Address - Fax:706-583-0217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD39590Medicare UPIN
GAP08133Medicare UPIN
GAF27230Medicare UPIN
GAD46265Medicare UPIN
GAD41025Medicare UPIN
GAC85985Medicare UPIN
GAR94550Medicare UPIN
GAP05301Medicare UPIN
GAD42279Medicare UPIN
GAG00727Medicare UPIN
GAG19133Medicare UPIN
GAG27079Medicare UPIN
GAD42052Medicare UPIN
GAP57704Medicare UPIN